Adult 2 Unit 6

Scope & practice of emergency nursing

High-acuity care is collaborative, time-limited and continuously reprioritized

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Consent

• Consent to examine and treat is part of the ED record

• Emergency treatment may proceed when the patient cannot consent, and delay would risk serious harm or death

• Document the patient’s condition, interventions, times, responses, and disposition

Privacy

• HIPAA applies in the ED

• Limit unnecessary exposure of personal information

• Patients involved in violent events may need aliases or restricted chart access per policy

EMTALA

• Provide a nondiscriminatory medical screening exam

• Stabilize emergency medical conditions

• If transfer is required: appropriate transfer, receiving acceptance, consent when possible, and documentation to travel with the patient

Safety first: violence in the ED

Recognize risk

• High stress

• Intoxication

• Psychiatric illness

• Long waits

• Conflict, weapons, and escalating verbal aggression can precede violence

Safety first: violence in the ED

Nursing actions

• Keep distance and access to an exit

• Remove potential weapons

• Use calm, clear communication

• Engage security early

• Follow restraint policy only when less restrictive measures fail

• Monitor restrained patients frequently

Safety first: violence in the ED

If gunfire occurs

Protect yourself first

Security/law enforcement must gain control before clinicians can safely provide care

YOU CANNOT HELP OTHERS IF YOU BECOME A VICTIM

Holistic care in a crisis

The emergency is medical — and emotional

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The ED is a transition point

Discharge planning begins before the discharge order

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Triage: sorting by urgency

Goal: rapid assessment and decision-making — not first come, first served

What the triage nurse collects

• Full vital signs + pain assessment

• Chief concern and event history

• Relevant medical/surgical history

• Neurologic assessment

• Weight and allergies

• Safety/IPV screening

• Needed protocol-based diagnostics

Triage is active care

• Basic first aid and bleeding control

• Protocol-driven x-rays, ECGs, urinalysis or simple medications when authorized

• Monitor the waiting room

• Reassess waiting patients

• Maintain safety and communicate with families

Emergency Severity Index (ESI)

A five-level system based on acuity and anticipated resource needs

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Four patients arrive at the same time. Who is seen first?

24-year-old with an ankle deformity, pain 9/10, pedal pulse present

68-year-old with crushing chest pain, pale/diaphoretic, BP 86/50

32-year-old with a 2-cm hand laceration and controlled bleeding

45-year-old with fever 101°F and dysuria for 2 days

The patient with chest pain, diaphoresis and hypotension

The most unstable patient receives priority. Hypotension plus ischemic symptoms signals an immediately threatening circulation problem; the other patients can safely wait for a brief period.

Why this matters

• Triage is based on current risk, not pain score alone.

• Reassessment matters: a waiting patient can move to a higher acuity level.

Primary survey: ABCDE

Find and treat life threats as you find them

DO NOT COMPLETE THE WHOLE ASSESSMENT BEFORE TREATING A LIFE THREAT

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Secondary survey

Only after immediate threats are addressed

• Complete health history + mechanism of injury

• Head-to-toe exam including posterior surfaces

• Diagnostic and laboratory testing

• Monitoring devices as indicated

• Splint fractures; cleanse/close/dress wounds

• Comfort, pain management and emotional support

REASSES, REASSES, REASSES

A trauma patient has a patent airway with cervical-spine protection maintained. What is the next priority?

Obtain the complete SAMPLE history

Assess lung sounds

Insert a urinary catheter

Complete a detailed neurologic exam

Assess lung sounds

Assess the airway while protecting the cervical spine. Once the airway is patent, assess breathing, ventilation and chest injury. Maintain cervical-spine protection throughout the survey.

Why this matters

• ABCs are not a checklist to complete; they are a treatment priority sequence.

• Any deterioration sends you back to the primary survey.

Acute airway obstruction

Partial obstruction can become complete obstruction quickly

Recognize cues

• Cannot speak, breathe, or cough

• Clutching the neck

• Stridor

• Labored breathing 

• Accessory muscle use

• Increasing anxiety/restlessness

• Cyanosis and LOC are late findings

If air exchange is effective

• Encourage forceful coughing and continuous spontaneous breathing efforts

• Monitor closely for deterioration

If obstruction is severe/complete

• For severe choking, begin obstruction-relief measures

• If unresponsive, start CPR with compressions

• Escalate airway support and reassess after relief

Acute airway obstruction: causes

The cause guides the response, while airway support remains the priority

What blocks the upper airway?

• Foreign body: food bolus, dentures or another aspirated object

• Swelling: anaphylaxis, angioedema or infection such as epiglottitis

• Injury: facial or neck trauma, inhalation injury or chemical burns

• Reduced airway tone or fluids: tongue displacement, blood, vomit or secretions

Who is at greater risk?

• Older adults with swallowing difficulty or age-related pharyngeal changes

• Patients with Parkinson disease, dementia or other neurologic impairment

• Patients taking sedatives or hypnotics that impair protective responses

Partial obstruction may progress to hypoxia, hypercarbia and arrest. Complete can lead to permanent brain injury or death in 3-5 minutes   

Acute airway obstruction: assessment

The first decision is whether the patient is moving air effectively

Rapid bedside assessment

• Ask: “Are you choking?” Can the patient speak clearly or cough forcefully?

• Look for neck clutching, retractions, accessory muscle use and drooling

• Listen for stridor, gurgling or reduced air movement, observe chest rise

• Assess respiratory effort, mental status and oxygen saturation repeatedly

Findings that demand action

• Weak or absent cough, inability to speak, or markedly reduced airflow

• Increasing distress, restlessness, confusion or exhaustion

• Cyanosis and loss of consciousness are late signs of worsening hypoxia

• Imaging, laryngoscopy or bronchoscopy may help after immediate airway needs

Treatment of an unstable airway takes priority over diagnostic testing

Initial management: effective air exchange

Immediate nursing actions

• Encourage forceful coughing while effective air exchange continues

• Stay with the patient and reassess speech, cough, breathing and alertness

• Provide oxygen as indicated and summon help if the condition worsens

• Keep suction and airway equipment ready for rapid deterioration

When management changes

• A weak cough, loss of speech or poor airflow signals severe obstruction

• Activate the emergency response and begin the appropriate airway intervention

• For a visible object, removal requires direct visualization and appropriate skill

• Avoid blind finger sweeps, which may push an object deeper

Continuous reassessment determines whether coughing remains effective

Severe choking: adult management

Foreign-body obstruction with poor airflow requires immediate action

Responsive adult

• Activate the emergency response system and obtain assistance

• Alternate 5 back blows with 5 abdominal thrusts

• Repeat until the object comes out or the adult becomes unresponsive

• Use chest thrusts in late pregnancy or if the abdomen cannot be encircled

If the adult becomes unresponsive

• Lower safely and begin CPR, starting with chest compressions

• Before breaths, open the airway and check for a visible object

• Remove a visible object if accessible. Avoid blind finger sweeps

• After relief, reassess breathing and circulation and continue appropriate support

2025 AHA guidance applies to severe foreign-body choking in adults.

Airway positioning and basic support

Nursing interventions depend on the cause and the protective reflexes

Opening and clearing the airway

• Head tilt–chin lift opens the airway when cervical injury is not suspected

• Use a jaw thrust with cervical-spine protection when trauma is suspected

• Suction blood, vomit and secretions using appropriate equipment

• Recheck chest rise and airflow after each intervention

Adjuncts and ventilation

• Oropharyngeal airway: unconscious patient without an intact gag reflex

• Nasopharyngeal airway: consider when an oral adjunct is not tolerated

• Avoid a nasal adjunct with suspected basilar skull fracture or facial trauma

• After opening the airway, assist inadequate breathing with bag-mask ventilation

An airway adjunct does not guarantee adequate ventilation

Airway positioning and basic support

Nursing interventions depend on the cause and the protective reflexes

Opening and clearing the airway

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Advanced airway management

Early preparation matters when basic measures cannot sustain oxygenation

Indications and procedures

Escalate for worsening swelling, inadequate ventilation or inability to protect the airway

Trained clinicians may use endotracheal intubation to secure the airway

A supraglottic device may provide temporary rescue ventilation when appropriate

A surgical airway may be required when intubation and oxygenation fail

The emergency nurse’s role

Call the airway team and prepare suction, oxygen, bag-mask and backup devices

Assist with preoxygenation and prescribed intubation medications

After intubation, monitor chest rise, bilateral breath sounds, SpO₂ and capnography

Secure the device and reassess ventilation, vital signs and patient response

Persistent obstruction or poor ventilation requires immediate escalation

A conscious adult is choking but has a strong cough and can move air. What should the nurse do first?

Encourage forceful coughing and closely monitor

Begin chest compressions

Insert a nasopharyngeal airway

Immediately perform endotracheal intubation

Encourage forceful coughing and closely monitor

A strong cough and continued airflow indicate effective air exchange

Encourage forceful coughing and closely monitor the patient

The patient can still move air and use an effective protective response

Continue assessing cough strength, speech, breathing and mental status

If the patient deteriorates

A weak or absent cough and inability to speak indicate severe obstruction

For a responsive adult with severe choking, alternate 5 back blows and 5 abdominal thrusts

If the patient becomes unresponsive, begin CPR with compressions

Hemorrhage & Shock

Basics

Control bleeding, maintain circulating volume for tissue oxygenation, and prevent shock

Traumatic Hemorrhage is the leading cause of PREVENTABLE DEATH after sever injury

Hemorrhage & shock

Control bleeding, maintain circulating volume for tissue oxygenation, and prevent shock

Recognize shock

• Cool, moist skin

• Falling BP

• Increasing HR

• Delayed capillary refill

• Decreasing urine output

• Anxiety/apprehension

Stop the bleeding

• Direct, firm pressure is first-line for external bleeding

• Use pressure dressings and immobilization

• Tourniquet for uncontrolled extremity hemorrhage; document application time

Restore perfusion

• Two large-gauge IVs, preferably in uninjured extremities

• Draw labs/type & cross

• Give prescribed fluids and blood components

• Warm large-volume blood products when possible

Control of external hemorrhage

Direct pressure and timely tourniquet use control life-threatening limb bleeding

Direct pressure and limb care

• Expose the wound and apply firm, continuous direct pressure

• Use a pressure dressing and wound packing when indicated and within training

• Immobilize the injured extremity to limit movement and further blood loss

• Use elevation for venous or capillary bleeding when feasible

Tourniquet application

• Use promptly for life-threatening limb bleeding, including bleeding pressure cannot control

• Place 2–3 inches proximal to the wound. Avoid joints and the wound itself

• Tighten until the is no palpable pulse. Secure the device and document the date and time

• Reassess bleeding. Leave in place for the surgical team to manage during definitive care

Elevation must not delay direct pressure, wound packing or tourniquet application

Hemorrhage: goals and fluid replacement

Stopping blood loss and restoring perfusion occur together

Goals of emergency management

• Control bleeding promptly

• Maintain adequate circulating blood volume for tissue oxygenation

• Prevent shock or reverse worsening tissue hypoperfusion

• Reassess mental status, pulse, blood pressure, skin perfusion and urine output

Why replace volume?

• Blood loss reduces circulating volume and venous return to the heart

• Lower preload can reduce stroke volume and cardiac output

• Volume replacement supports circulation while the team controls the source

• Use prescribed fluids and early blood products for major hemorrhage. Avoid excessive crystalloid

Hemorrhage: IV access and blood sampling

Rapid access supports resuscitation and timely transfusion

Large-bore access

• Place two large-bore peripheral IV catheters when feasible

• For adult rapid resuscitation, 14–16 gauge is a typical target

• Prefer veins in unaffected or uninjured extremities.

• Use the best available access immediately and escalate if peripheral access fails

Before transfusion, when feasible

• Obtain blood samples for typing, antibody screening and crossmatching if it does not delay care

• Send prescribed baseline labs

• Emergency-release blood may be needed before crossmatching is complete

Massive blood loss: blood component replacement

Activate the massive transfusion protocol when indicated

What each component provides

• Packed red blood cells restore oxygen-carrying capacity

• Plasma supplies multiple coagulation factors

• Platelets support primary hemostasis

• Cryoprecipitate or fibrinogen concentrate may treat low fibrinogen, as prescribed

Protocol and laboratory guidance

• Major hemorrhage may require balanced components or whole blood per local protocol

• Follow the MTP and reassess ongoing blood loss and coagulation results

• Factors XII, XI, IX and VIII are part of the intrinsic coagulation pathway

• They are not a stand-alone replacement list for massive blood loss

Red cells alone do not replace platelets or all coagulation proteins

Blood warming during major resuscitation

Rapid infusion of refrigerated blood can lower core temperature

Why warming matters

• Several units of cold blood can produce a substantial cooling effect

• Hypothermia impairs clotting and contributes to coagulopathy

• Severe hypothermia can cause dysrhythmias and cardiac arrest

• Warm the patient and prevent further heat loss during resuscitation

Nursing actions

• Use an approved blood warmer for rapid or large-volume transfusion when possible

• Follow device instructions and blood-bank policy for each product

• Monitor temperature, ECG, vital signs and the response to transfusion

• Watch for transfusion reactions and prescribed electrolyte monitoring, including ionized calcium

Trauma triad and diamond of death

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These problems reinforce bleeding and poor perfusion. Address them together.

Trauma triad and diamond of death

Nursing priorities

Hypothermia

Limit exposure. Warm the patient and use approved fluid/blood warmers

Acidosis

Control hemorrhage and restore perfusion. Trend lactate, pH and base deficit

Coagulopathy

Activate MTP when indicated. Monitor coagulation and give prescribed components

Hypocalcemia

Trend ionized calcium, especially during transfusion. Replace calcium per protocol

Internal hemorrhage: think compartments

Shock without visible blood is still hemorrhage until proven otherwise

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Intra-abdominal injuries

Blunt injuries can be deceptively quiet

Assess

• Distention

• Guarding

• Tenderness and rebound tenderness

• Rigidity

• Shock

• Referred shoulder pain

Diagnostics

• Serial H/H and abdominal exams

• Lactate, ABG, INR

• DPL, FAST/ultrasound or CT depending on stability.

Evisceration

• Do not replace organs

• Cover with sterile, moist saline dressings

• Keep NPO

• Prepare for definitive care

Abdominal trauma: mechanisms and injury patterns

Mechanism guides suspicion, while stability and findings guide management

Penetrating injury

• Gunshot and stab wounds may injure hollow organs, solid organs or vessels

• Small-bowel injury is a concern. The liver is vulnerable because of its size and location

• Gunshot tissue damage depends on energy transfer, velocity and trajectory

• Count and document all wounds. External wounds do not reveal the full internal path

Blunt injury

• Common mechanisms include crashes, falls, blows and explosions

• Liver, spleen, kidney and vascular injury can cause major concealed hemorrhage

• Chest, head and extremity injuries may coexist and distract from the abdomen

• Early findings may be subtle. Reassessment is essential as injuries evolve

A small surface wound can conceal extensive internal injury.

Genitourinary injury: assessment before catheterization

Suspected urethral injury changes the plan for urinary drainage

Possible injury cues

• Pelvic or genital trauma, hematuria, blood at the meatus or inability to void

• Perineal bruising, genital injury or other findings suggesting urethral disruption

• A high-riding prostate in males may indicate an urethral injury, but cannot rule injury in or out alone

• Rectal or vaginal examination may be indicated and requires an appropriate clinician

Catheter precautions

• Do not attempt routine blind urethral catheterization when injury is suspected

• Notify the trauma team and obtain urologic evaluation as indicated

• Once safe drainage is established, monitor urine output, appearance and perfusion.

Wounds & forensic evidence

Treat the patient first — but do not destroy evidence

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Multisystem trauma

The least dramatic injury can be the most lethal

Highest priority

Any injury interfering with airway, breathing or circulation is an immediate threat and is treated first

Trauma nurse role

Assess/monitor, maintain airway and IV access, administer medications, obtain specimens and document patient response

Prevent the lethal diamond

Prevent hypothermia, acidosis, coagulopathy and hypocalcemia. Warm the patient and monitor perfusion, clotting and ionized calcium

Trauma is the 4th leading cause of death in the U.S. Leading cause of death in children and adults under 44 years old

Crush injury

Think beyond the visible limb

Immediate concerns

• Hypovolemic shock

• Spinal cord injury

• Fractures/soft-tissue injury

• Acute kidney injury

Rhabdomyolysis

• Damaged muscle releases myoglobin

• Watch for muscle pain/weakness and dark urine

• CK and renal function are key

• Volume replacement helps prevent AKI

Compartment syndrome

• Escalating pain, paresthesia/burning, pallor, poikilothermia, and later pulselessness suggest rising compartment pressure

• Requires urgent evaluation and possible fasciotomy

Fractures in the ED

Treat the whole patient before the extremity — unless the extremity is pulseless

• ABCs first; assess for neurologic, chest and abdominal injury

• Check distal pulse, color, temperature, sensation and movement

• Handle gently and minimize movement

• Splint before moving; immobilize joints above and below injury

• Recheck neurovascular status after splinting

• Pulseless extremity → urgent realignment/reduction per emergency team plan

MVC patient: open femur fracture, RR 34, absent breath sounds on the left, BP 92/60. What should happen first?

Splint the femur immediately

Give IV opioid medication for pain

Address the breathing problem

Give antibiotics to avoid infection

Address the breathing problem first

Breathing compromise is an immediate threat to life and takes priority over limb injury. Life-saving interventions and trauma assessment occur simultaneously across the team.

Why this matters

• “Most dramatic” is not the same as “most lethal.”

• After stabilization, return to hemorrhage control, fracture care and full secondary survey.

Heat stroke

Hyperthermia + CNS dysfunction = medical emergency

Recognize

• Very high core temperature < 105°

• Altered mental status/CNS dysfunction

• Nausea and vomiting

• Tachycardia

• Tachypnea

• Hypotension

• Exertional or nonexertional patterns may occur

Immediate management

• ABCs

• Rapid cooling

• IV fluids as prescribed

• Continuous monitoring

• Treat seizures and electrolyte problems as ordered

Watch for complications

• Rhabdomyolysis

• Kidney injury

• Dysrhythmias

• Coagulopathy

• Multisystem dysfunction

Frostbite

Frozen tissue is fragile tissue

Findings

• Hard, cold, numb or insensitive tissue

• May look white/mottled

• Redness and severe pain may emerge during rewarming

Rewarm

• Controlled, rapid rewarming in circulating warm water (98.6° - 104°) for 30-40 minute intervals 

• Provide analgesia

• Remove constricting jewelry/ wet clothing

• Elevate after rewarming

Do NOT

• Do not massage or rub

• Avoid walking on frostbitten feet/legs

• Do not rewarm if refreezing is likely before definitive care

Hypothermia

Core temperature ≤ 35°C (95°F)

Priority

• Treat hypothermia before localized frostbite

• Handle gently because the cold myocardium is irritable

Rewarming

• Remove wet clothing

• Passive external warming for milder cases

• Active core methods may include warmed IV fluids, humidified oxygen and advanced rewarming strategies

Monitor

• Continuous cardiac monitoring, temperature and hemodynamics

• Cold peripheral blood returning centrally can contribute to dysrhythmias/electrolyte problems

Compare the environmental emergencies

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Which action requires correction?

Rapidly cooling a confused patient with a core temperature of 105°F

Giving analgesia before frostbite rewarming

Massaging a frostbitten foot to restore circulation

Removing wet clothing from a hypothermic patient

Massaging a frostbitten foot to restore circulation 

Rubbing can injure vulnerable tissue and cause additional damage

Nonfatal drowning

Immediate care

• Resuscitate airway/breathing/circulation

• Oxygenate and ventilate

• Intubation may be required

• Monitor ABGs and ECG

• Monitor core temperature and initiate hypothermia interventions, if needed

Associated problems

• Acidosis

• Hypothermia

• Hypoxia

• Aspiration-related lung injury

• Delayed respiratory deterioration

Nursing mindset

A patient who initially “looks okay” after submersion still needs close evaluation because respiratory complications can evolve

Animal & human bites

Wound care + infection prevention + public health

Animal bites

• Assess wound depth

• Infection risk

• Neurovascular status

• Determine rabies risk

• Report to proper public health agency

Human bites

• High bacterial burden and infection risk

• Consider assault/sexual assault context

• Document carefully

• Photograph per policy and preserve forensic evidence when applicable

Snakebite

Treat as venomous until evaluated

Do

• ABCs

• Remove constricting items

• Clean the wound

• Immobilize the extremity

• Serially assess swelling, perfusion, and systemic symptoms

• Prepare for antivenom when indicated

Do NOT

• Do not cut/incise

• Do not Suction

• Do not apply ice or use a tourniquet

• Do not handle the snake — even if it appears dead

Monitor

• Progressive edema/ecchymosis

• Bleeding

• Nausea/vomiting

• Neurologic symptoms and

• Allergic reactions during antivenom administration

Spider & tick bites

Timing and symptom pattern matter

Brown recluse

• Often initially painless

• Symptoms can evolve over 24–72 hours

• Fever, chills, N/V, joint pain

• Tissue necrosis may develop later

• Wound care and follow-up are important

Black widow

• Pinprick sensation followed by systemic symptoms within 30 minutes

• Severe pain/spasm, abdominal rigidity, hypertension, tachycardia

• Ice, elevation, tetanus status

• Cardiopulmonary monitoring may be needed

• Antivenom

Tick

• Remove with tweezers using a straight upward pull

• Document location/exposure

• Educate patients about symptoms of tick-borne disease

Poisoning: universal goals

Route matters, but the first priorities are consistent

1. Remove or inactivate the poison

2. Support vital organ function

3. Give a specific antidote when indicated

4. Enhance elimination when appropriate

Always ask: WHAT substance? HOW MUCH? WHEN? WHICH route? What symptoms are present now?

Ingested poisons

ABCs first — then toxin-specific treatment

Assess

• ABCs

• Vital signs

• LOC

• ECG

• Urine output

• Labs

• Determine substance, amount, time, patient age/weight and signs of tissue injury

Decrease absorption

• Emetics or Cathartics

• Activated charcoal may be used for selected toxins

• Gastric decontamination is not routine and depends on the substance, timing and patient condition

• Administer specific antagonist as early as possible

• Other treatment may include dialysis, diuresis, or hemoperfusion

Critical caution

Do not induce vomiting after corrosive acid or alkali ingestion because re-exposure can worsen tissue injury

Carbon monoxide poisoning

Normal-looking SpO₂ does not exclude tissue hypoxia

Mechanism

CO binds hemoglobin with far greater affinity than oxygen, forming carboxyhemoglobin and reducing oxygen delivery

Cues

• Headache

• Weakness

• Dizziness

• Confusion

• Altered LOC

• Nonspecific “flu-like” symptoms

• Multiple ill household members are a clue

Treatment

• Remove from exposure

• Support ABCs 

• Loosen tight clothing

• Keep patient warm

• No smoking or drinking

• Administer 100% oxygen

• Hyperbaric oxygen may be considered in selected severe cases

Skin contamination & food poisoning

Protect yourself before you become the second patient

Chemical skin exposure

• PPE for staff

• Identify the substance

• Remove contaminated clothing

• Brush off dry agents when appropriate before irrigation

• Copious water irrigation for many chemicals

• Some agents require specific decontamination procedures

• Follow-up evaluation at 24 hours, 72 hours, and 7 days

Food poisoning

• ABCs and supportive care

• Determine what was eaten and timing of symptoms

• Correct fluid/electrolyte losses

• Control nausea/vomiting

• Monitor for neurologic or respiratory involvement — botulism can cause respiratory paralysis and death

A worker arrives after an unknown industrial chemical spills onto the uniform and skin. What is the nurse’s first priority?

Bring the patient directly into the main treatment area

Protect staff and initiate appropriate decontamination 

Apply an occlusive dressing over the affected skin

Give oral activated charcoal

Protect staff and initiate appropriate decontamination 

Mobilize properly protected personnel to address immediate threats. Direct entry into the main care area can expose others.

Why this matters

Decontamination should occur according to the substance and institutional protocol before the contaminated patient enters the main treatment area when feasible.

Drug overdose

Treat physiology before the history is complete

Immediate goals

• Support respiratory and cardiovascular function

• Monitor oxygenation, ECG, mental status and temperature

• Give antidotes when indicated

Enhance clearance

• Management depends on the substance

• May include activated charcoal, specific antidotes, or advanced elimination methods for selected agents

Safety & follow-up

• Protect the patient and staff

• Once medically stabilized, evaluate self-harm risk and connect the patient to substance-use and harm-reduction resources

Table 67-1 identifies common drugs, their manifestations, and therapeutic treatments

Acute alcohol intoxication

Do not let “intoxicated” become the diagnosis of convenience

Assess first

• Maintain airway

• Monitor for CNS depression and hypotension

• Check glucose

• Look for head injury or other conditions that mimic intoxication

Behavior

• Use a calm, nonjudgmental approach

• Safety may require additional personnel or medication for severe agitation

Before disposition

• Assess injuries, withdrawal risk and underlying illness

• Screening, brief intervention and referral are opportunities for ongoing care

Alcohol withdrawal syndrome

Symptoms rise as alcohol levels fall

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A patient who stopped drinking yesterday is tremulous, anxious, tachycardic and hypertensive. What is the nurse most concerned about?

Expected uncomplicated intoxication

Progression toward delirium tremens

Carbon monoxide poisoning

Opioid overdose

Progression towards delirium tremens

Recent cessation with tremor, anxiety, tachycardia and hypertension raises concern for worsening alcohol withdrawal and can progress to hallucinations and delirium tremens

Why this matters

• Delirium tremens is a medical emergency

• Treat with benzodiazepines and a combination of other medications to establish and maintain sedation, reduce agitation, prevent exhaustion and seizures, and promote sleep

Sexual assault

The manner in which the patient is received can affect long-term recovery

Immediate approach

• See the patient promptly

• Provide privacy

• Explain each step

• Obtain consent for each component of care

• Avoid judgmental language

Forensic care

• Follow facility protocol

• SANE-trained nurses complete specialized evidence collection, photography, history and documentation

Treat consequences

• Assess injuries

• Address pregnancy and STI risks as appropriate

• Provide emotional support, crisis resources and follow-up

Human trafficking

The ED may be the patient’s only contact with health care

Possible cues

• Injury with a controlling companion

• Chronic runaway/homelessness history

• Poor healing

• Fear, agitation, cowering or deferring to companion

• Inconsistent story

Create privacy

• Find a safe opportunity to speak with the patient alone

• Use professional interpreters rather than the companion when language support is needed

Ask targeted questions

• Control of money/phone

• Freedom to come and go

• Who is accompanying them

• Whether they feel safe

• The patient may decline assistance

• Offer trafficking hotline safely

Psychiatric emergencies

Safety

• Determine risk of harm to self or others

• Control the environment 

• Remove dangerous objects

• Use the least restrictive approach possible

Communication

• Introduce yourself

• Be aware of your body language

• Explain that you are there to help

• Use simple one-thought statements

• Listen and preserve the patient’s dignity

Assessment

• Rule out medical/toxic causes

• Determine psychiatric history/current care/compliance

• Assess suicidal potential and initiate crisis intervention and appropriate referral/admission

A frightened patient arrives with an older companion who answers every question and refuses to leave. What is the best nursing action?

Ask the companion to provide the full history because the patient seems anxious

Create an opportunity to speak with the patient privately and assess safety

Confront the companion about suspected trafficking in front of the patient

Discharge the patient if they deny abuse while the companion is present

The goal is not to “rescue” by force. It is to create a safe opportunity for disclosure and help.

Create an opportunity to speak with the patient privately and assess safety

A private safety assessment gives the patient an independent voice. 

The goal is not to “rescue” by force. It is to create a safe opportunity for disclosure and help.

Rapid-fire review

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Five take-home priorities

Safety comes first — for the patient, staff, and environment

Treat the life threat before completing the full assessment

Reassess constantly; ED priorities can change in minutes

Look for hidden problems: internal bleeding, occult injury, medical mimics and delayed deterioration

Emergency nursing includes privacy, family support, documentation, discharge planning and follow-up — not only resuscitation

What makes an event a disaster?

The problem is not simply the number of patients — it is demand exceeding available resources.

Mass-casualty incident

• Large number of casualties

• Available resources become scarce

• Priorities shift to population benefit

Natural / public health

• Storms, floods, earthquakes, fires

• Outbreaks, epidemics, pandemics

• Loss of utilities and infrastructure

Human-caused / terrorism

• Transportation incidents

• Chemical or toxic releases

• Explosive, biologic, radiologic/nuclear events

Disaster mindset: protect responders → organize resources → triage rapidly → reassess continuously

Command structure keeps the response organized

NIMS provides the framework; ICS/HICS provides a common command structure.

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Emergency Operations Plan (EOP)

A flexible plan built before the crisis.

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The nurse’s role during a disaster

Scope may expand — safety, competence, delegation, and communication still matter.

• Know the hospital disaster plan and participate in drills

• Perform rapid assessment, triage, essential care, documentation, and patient tracking

• Delegate based on the skills of available staff, students, and volunteers

• Protect personal safety and use appropriate PPE before entering a hazardous environment

• Balance individual patient needs with fair allocation of scarce resources

• Support patients, families, colleagues, and vulnerable populations during and after the event

Ethical shift

Routine care asks: “What is best for this patient?”

Disaster care also asks: “How do we use limited resources to achieve the greatest good for the greatest number?”

Routine ED triage ≠ disaster triage

The priority logic changes when resources are scarce.

Routine ED triage

• Highest priority to the most critically ill

• Resources concentrated on individual need

• Goal: best outcome for each patient

Disaster / MCI triage

• Priority based on survivability and resource use

• Rapid sorting followed by repeated reassessment

• Goal: greatest good for the greatest number

Key implication: the sickest-looking patient may not receive the most resources first during an MCI.

Mass-casualty triage categories

Tag color communicates urgency and expected resource use.

START: adult mass-casualty triage

A rapid physiologic screen performed in under a minute.

Step 1 — Walking

Patients who can walk are initially MINOR / GREEN and moved for secondary triage

Step 2 — RPM

Respirations → Perfusion → Mental status 

Any major abnormality moves the patient to IMMEDIATE / RED

Step 3 — Reassess

Triage is dynamic

Category can change as the patient deteriorates, improves, or resources change

Adult START anchors: RR >30 • absent radial pulse or cap refill >2 sec • cannot obey commands → RED

START Adult Triage Flowchart

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JumpSTART: pediatric adaptation

Children can be apneic from respiratory failure while still having a pulse.

If apneic

• Open/position airway

• Check for palpable pulse

• If pulse is present, give 5 rescue breaths

• Breathing resumes → RED

Respiratory rate

• <15 or >45 breaths/min → RED

• 15–45 → continue assessment

Neurologic assessment

• Inappropriate response to pain or unresponsive → RED

• Alert, verbal, or appropriate response to pain → may be YELLOW

Use JumpSTART when the patient appears to be a child; use an adult system when the adolescent appears physiologically adult.

JumpSTART Triage Flowchart

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SALT: sort → assess → lifesaving interventions → treatment/transport

SALT is an all-hazards framework that begins with a global sort.

SORT

Walk → assess 3rd

Wave/purposeful movement → assess 2nd

Still/obvious life threat → assess 1st

ASSESS

Individual assessment plus rapid lifesaving interventions

ASSIGN

Minimal • Delayed • Immediate • Expectant

REASSESS

Patient condition, resources, and scene safety can change the category

Triage Practice 1 - Assign one color tag to each patient

Patient 1

Young adult male: capillary refill >3 seconds, obvious penetrating abdominal injury, pale and moaning.

Patient 2

Middle-aged female: capillary refill <2 seconds, several abrasions, calf laceration, right-leg pain, difficulty walking; follows commands and has no respiratory distress.

Patient 1

RED

Poor perfusion alone makes this patient IMMEDIATE / RED. The penetrating abdominal injury reinforces the concern for hemorrhagic shock.

Patient 2

YELLOW

She is not able to walk normally but has acceptable perfusion and mental status without respiratory compromise. She can be DELAYED / YELLOW.

Triage Practice 2 - Assign one color tag to each patient

Patient 1

Adolescent who appears physiologically adult: found near a fire, remains apneic after airway repositioning.

Patient 2

Older adult female: capillary refill >4 seconds, penetrating abdominal injury with active bleeding, vomiting, alert and oriented.

Patient 1

BLACK

Under adult START, persistent apnea after opening/repositioning the airway is EXPECTANT / BLACK.

Patient 2

RED

Delayed capillary refill indicates poor perfusion. In START this is IMMEDIATE / RED even though she is alert.

Triage Practice 3 - Assign one color tag to each patient

Patient 1

Toddler: bloody nose, nasal pain/swelling, bruising around the left eye, alert and appropriately responsive, breathing comfortably.

Patient 2

Older adolescent/young adult female: chest pain, abdominal bruising and laceration, open right-wrist fracture, capillary refill <2 seconds, RR 20, follows commands.

Patient 1

GREEN

This child has minor injuries without respiratory, perfusion, or neurologic compromise. She is MINOR / GREEN.

Patient 2

YELLOW

Respirations, perfusion, and mental status are stable. Significant injuries require care, but she can be DELAYED / YELLOW.

Triage Practice 4 - Assign one color tag to each patient

Patient 1

Middle-aged male: crush injury to right hand, follows commands, pulses present, RR 14, able to walk.

Patient 2

Young adult female: abdominal pain/bruising, obvious left-wrist deformity, capillary refill <2 seconds, follows commands, anxious; not in respiratory distress.

Patient 1

GREEN

A patient who can walk is initially classified MINOR / GREEN and moved for secondary triage.

Patient 2

YELLOW

She has significant injuries but no START physiologic trigger for RED. DELAYED / YELLOW is appropriate.

PPE levels: match protection to the hazard

Standard hospital PPE may be inadequate for chemical, biologic, or radiologic contamination.

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PPE Levels 

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Decontamination protects the patient — and the hospital

Do not assume prehospital decontamination was complete.

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Decontamination Zones 

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Natural disasters: expect the surge to arrive in waves

Infrastructure failure often complicates the clinical response

Wave 1

Minimally injured patients often self-present first

Wave 2

Severely injured patients arrive after organized rescue and transport

Wave 3

Patients discovered later during rescue, extrication, or cleanup activities

Common operational threats: loss of communication • electricity • potable water • transportation • sanitation

Outbreak → epidemic → pandemic

Outbreak

Occurrence of disease within a population that exceeds normal expectations

Epidemic

A widespread outbreak within a community or population that exceeds expected incidence

Pandemic

An epidemic that spreads across multiple countries or continents

Watch for unusual clusters, unexpected deaths, travel/exposure patterns, and a sudden increase in similar symptoms.

Blast injury: mechanism predicts hidden injury

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Chemical agents: protect yourself first

Remove from exposure, decontaminate, support ABCs, then give agent-specific therapy.

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Biologic agents: recognize patterns that do not look “normal”

Many biologic agents initially mimic common illnesses.

• Look for unusual clusters of similar illness, unexpected severity, or cases linked to a common event/location.

• Use appropriate PPE, isolation or quarantine when indicated, and public-health reporting pathways.

• Category A agents highlighted in the chapter include anthrax, botulism, tularemia, viral hemorrhagic fevers, smallpox, and plague.

• Treatment is organism-specific; early recognition and prophylaxis can be critical for exposed populations.

Clinical clue

A pattern matters more than a single symptom.

Ask about occupation, environment, travel, recent gatherings, sick contacts, and sudden/unexpected deaths.

Radiologic / nuclear events

Contamination and radiation exposure are related — but not the same problem.

External contamination

• Survey patient radiation levels before decontamination

• Remove contaminated clothing

• Soap-and-water decontamination

• Resurvey after washing

Protect staff

• Water-resistant gown, gloves, mask/eye protection as indicated

• Use dosimetry and involve radiation safety

• Contain runoff and contaminated belongings

Acute radiation syndrome

• Hematopoietic system affected early

• GI and CNS effects occur with higher doses

• Infection, bleeding, fluid/electrolyte problems may follow

Chest trauma: blunt or penetrating

Blunt trauma

• MVCs, falls, bicycle/handlebar impact, blows

• May hide severe internal injury

• Chest wall, lung, pleura, heart, great-vessel injury

Penetrating trauma

• Stab wounds, gunshot wounds, impaled objects

• Any thoracic structure can be injured

• Common consequences: pneumothorax, hemothorax, tamponade

Three lethal physiologic pathways: HYPOXEMIA • HYPOVOLEMIA • CARDIAC FAILURE

Initial assessment: find what can kill the patient now

Look

• Respiratory rate/depth

• Chest symmetry and paradoxical motion

• Open wounds / entrance and exit wounds

• Cyanosis, diaphoresis, shock signs

Listen

• Bilateral breath sounds

• Stridor or diminished/absent breath sounds

• Voice/airway changes

• Patient reports of air hunger or chest pain

Feel / monitor

• Tracheal position

• Neck veins

• Crepitus / subcutaneous emphysema

• SpO₂, ECG, ABG; trend vital signs

Sternal and rib fractures

Pain can create its own respiratory complication.

Nursing priorities

• Assess for associated pneumothorax, hemothorax, pulmonary contusion, or organ injury.

• Control pain enough to permit deep breathing and coughing — avoid oversedation.

• Encourage incentive spirometry and pulmonary hygiene to prevent splinting and atelectasis.

• Reassess oxygenation, respiratory effort, and breath sounds.

Pain → shallow respirations → retained secretions / atelectasis → hypoxemia

Flail chest

≥3 adjacent ribs fractured in ≥2 places creates a free-floating segment.

What the nurse sees

• Paradoxical chest-wall movement

• Hypoxemia, increased work of breathing

• Pain, retained secretions, atelectasis

• Often associated pulmonary contusion

Management: oxygen/ventilatory support + secretion clearance + aggressive pain control. 

Severe respiratory failure may require intubation and mechanical ventilation.

Flail chest

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Pulmonary contusion

Hemorrhage + edema in lung tissue → impaired gas exchange that may worsen over time.

Clinical pattern

• Tachypnea, tachycardia, chest pain

• Hypoxemia; crackles; blood-tinged secretions

• Agitation or confusion may reflect hypoxemia

• Initial chest x-ray can be normal — infiltrates may appear 1–2 days later

Priorities: maintain airway/oxygenation • control pain • mobilize secretions • avoid fluid overload • escalate ventilatory support if needed

Pulmonary contusion

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Penetrating chest trauma

Expose completely, identify all wounds, and assume associated injury until ruled out.

• Maintain airway and ventilation; rapidly assess for shock.

• Inspect for entrance and exit wounds and injuries below the diaphragm.

• Type and crossmatch; establish large-bore IV access and monitor urine output when indicated.

• Chest tube drainage is common when air or blood accumulates in the pleural space.

• Heart, great-vessel, esophageal, or tracheobronchial injury may require urgent surgery.

Pneumothorax: air in the pleural space collapses lung tissue

Negative intrapleural pressure is lost when the pleura is breached.

Simple

Air enters pleural space; no progressive pressure buildup

Open / traumatic

Chest-wall opening allows air to move through the wound

Tension

One-way valve effect traps air → rising intrathoracic pressure → obstructive shock